THE EFFECT OF VCT TESTING AND UPTAKE OF HIV/ART CARE ON MODERN CONTRACEPTIVE USE AMONG WOMEN IN RAKAI, UGANDA

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1 THE EFFECT OF VCT TESTING AND UPTAKE OF HIV/ART CARE ON MODERN CONTRACEPTIVE USE AMONG WOMEN IN RAKAI, UGANDA Fredrick Makumbi; Gertrude Nakigozi; Tom Lutalo; Joseph Kagaayi; Joseph Sekasanvu; Absalom Settuba; David Serwada; Maria Wawer; Ronald Gray Family Planning conference, Kampala, Uganda November th 2009

2 Background Fertility in SSA is high and contraceptive use is low Knowledge of contraceptives is almost universal Uganda (UDHS 2006) 98% know at least one method Modern method use 18%, Increasing use of modern methods over time Modern contraceptive use is low among HIV+ women 30% among women on HAART in Mbarara (Am J Public Health Feb;99(2):340-7.) Integration of FP into VCT and HIV care could increase modern contraceptive use

3 Objective To assess the effect of VCT uptake and enrolment into ART/HIV care on use of modern contraceptives and condoms for family planning among women aged years in Rakai, Uganda.

4 Methods-1 A population-based cohort in 50 rural villages in Rakai since 1994 Annual follow-up of all persons aged year Data collection Census (marital status, sex, age, household possessions, structure) re) Detailed survey, with individual interviews and blood for HIV testing Information on pregnancy status, fertility desires, use of FP methods, m receipt of HIV test results (VCT) in past 12 months Enrolment into HIV care including ART from RHSP HIV care clinics

5 Methods-2 Data from RCCS survey Follow up visits for women years Non-pregnant, currently married or single women, sexually active in past 12 months Exclude sterilization VCT acceptance in past 12 months Enrolment into HIV care before survey visit

6 HIV care program Methods-3 started June 2004, Supported by PEPFAR Services offered via 17 mobile community-based out-patient clinics, called Suubi or Hope clinics Reproductive health education including use of Family planning, prevention messages Provide HIV basic care package, which includes condoms ART, general HIV care, PMTCT VCT services in RHSP Pretest counseling and blood draw during the community surveys and at HIV clinics HIV results returned by community resident trained HIV counselors

7 Statistical Analysis-1 A cross sectional analysis to assess prevalence of modern contraceptive and condoms for FP Outcome defined as use of modern Family Planning Non-users as a referent group condoms-only only Modern methods (pills, injections, IUD, and Norplant) Dependent variables Uptake of VCT in the past 12 months prior to the survey Enrolment into HIV care if HIV+ whether started on ART or not

8 Statistical Analysis-2 Multinomial logistic regression Estimated unadjusted and adjusted Odds ratios (OR) and 95% confidence intervals (CI) Condoms-only only versus Non-users Modern methods versus Non-users OR of outcomes comparing VCT recipients to non- recipients, and HIV care/art enrollees to non-enrollees Factors adjusted for included age, HIV status, desired number of lifetime children, child spacing, education level All stratified by marital status STATA version 9.2

9 Results -1 Characteristics of married and sexually active unmarried women unmarried % Married % Total , Age (years) Mean (SD) 30.0(8.4) 31.1(7.4) Median (IQR) 30.0(23,36) 30.0(25,36) Age group Desire for child within 2- yrs No , Yes, within 2-years Ever VCT receipt Never received Ever received

10 HIV prevalence, VCT receipt status and HIV care among non-pregnant women HIV prevalence by marital status VCT receipt in past 12m by marital status 60 Proportion(%) % Unmarried 11.9% Married Positive Proportion(%) % 47.7% Unmarried Married Marital status Received HIV+; 25.0% unmarried, 11.9% married VCT; 54.8% unmarried, 47.7% married Enrollment into HIV care among HIV+ Proportion (%) Care and on ART Care, not on ART Not in care 0 Unmarried Married Marital status HIV+ in care; 57.1% unmarried; 52.1% married

11 Contraceptive use among women NOT desiring children in the next 2 years Contraceptive use Prop ortion(% ) Unmarried Married condoms-only Modern methods Use of condoms-only is more common in the unmarried compared to the married Use of modern methods is more common in married compared to unmarried

12 Contraceptive use among women NOT desiring children in the next 2 years Contraceptive use, among HIV+ Proportion(% ) Unmarried Married condoms-only Modern methods 0.0 Not in CARE In care, no ART In care, on ART Not in CARE In care, no ART In care, on ART Use of condoms-only is more common except for married women Not in care Appears an increasing trend in condom use with increasing level of HIV care

13 Results -2, Married Proportions and OR, among married women Condoms-only Modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total VCT & discussion ** No receipt Received-discussed (1.15,2.38) (1.03,1.66) Received +discussed (1.45,2.45) (0.83,1.18) HIV status Negative Positive (2.64,4.78) (0.82,1.38) * Adjusted for age, number of desired children, spacing; ** unmarried had no discussion with partner variables VCT and HIV+ status were associated with higher use of condoms VCT without result discussion was associated with higher use of modern methods

14 Results -2, Unmarried Proportions and OR, unmarried women Condoms-only modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total VCT & discussion ** No receipt Received (1.01,1.77) (0.91, 1.74) HIV status Negative Positive (1.49,2.87) (0.90,1.91) * Adjusted for age, number of desired children, spacing; ** unmarried had no discussion with partner variables VCT and HIV+ status were associated with higher use of condoms but not modern methods

15 Results -3, HIV+ Married Proportions and OR, among married HIV+ Condoms-only modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total VCT & discussion ** No receipt Received-discussed ** (0.64,3.06) (0.66,2.50) Received +discussed (0.87,3.28) (0.65,2.27) Enrollment into HIV care HIV+ Not in care Care, No ART (1.96,8.36) (0.62,2.14) Care, On ART (4.70, 24.61) (0.68,3.39) * Adjusted for age, number of desired children, spacing; ** Being in HIV care is strongly associated with higher use of condoms for FP

16 Results -3, HIV+ Unmarried Proportions and OR, among unmarried HIV+ Condoms-only modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total VCT & discussion ** No receipt Received-discussed ** (0.98,3.47) (0.98, 2.91) Enrollment into HIV care HIV+ Not in care Care, No ART (0.33,1.45) (0.71,2.54) Care, On ART (0.43,2.20) (1.30,5.07) * Adjusted for age, number of desired children, spacing; ** Being on ART is strongly associated with higher use of modern methods

17 Summary of other findings Factors associated with non-use of contraceptives desire for family size of 6 or more children Desire for a child within two years Older age, years Factors associated with increased use of contraceptives Education level, primary or higher Being a student, or working for money (among married) Condom use as FP method was more common among unmarried women, 35.5 % compared to the married, 10.0% However, modern contraceptive was more common among Married women, 31.1% compared to the unmarried, 21.0%

18 Conclusion VCT receipt, especially among HIV+, and HIV care programs can increase contraceptive use especially condoms, but more needs to be done to increase the modern methods High fertility desires still significantly determine contraceptive use in this rural setting

19 Recommendation Strategies to address desire for high fertility need to be developed, or strengthened There is need to strengthen FP services in VCT and HIV care programs, with promotion of modern contraceptive methods

20 Acknowledgements Rakai Health Sciences Management & Staff Rakai district leadership including community leaders Cohort participants Rakai Funders who have enabled continued research activities

21 Thank you